Provider Demographics
NPI:1962483388
Name:LEWIS, JACQUELINE (CNM)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95000-2428
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2428
Mailing Address - Country:US
Mailing Address - Phone:212-844-8592
Mailing Address - Fax:
Practice Address - Street 1:10 UNION SQ E
Practice Address - Street 2:BIMC DEPT OF OB GYN
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3314
Practice Address - Country:US
Practice Address - Phone:212-844-8592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY430433207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01596794Medicaid
S00825Medicare UPIN
NYM2M721Medicare ID - Type Unspecified